Keith Loud, MD, MSc: Medicaid cuts are a direct assault on our children’s health

July 30, 1965, was one of the most significant days in the history of healthcare in our country. It was the day President Lyndon B. Johnson signed into law landmark legislation that established the Medicare and Medicaid programs – guaranteeing health insurance for some of our most vulnerable populations, including children, pregnant mothers, and individuals with disabilities. 

At Dartmouth Health Children’s, where I serve as physician-in-chief, we see countless children like Lucas, a 14-year-old boy who lives with his parents and older sister at their home in Rochester, NH, and for whom supplemental Medicaid coverage is critical. Lucas was born five weeks early with Down syndrome and had several serious medical complications: he suffered from seizures, underwent cardiac surgery, required a tracheostomy, and had his airway surgically reconstructed. Later, he was diagnosed with autism spectrum disorder, requiring treatment with psychiatric medications to help manage his mood and behavior. Throughout Lucas’ life, his family has faced a mountain of medical bills that have accrued from hospital visits, daily home supports, and long-term home healthcare.

Lucas’ family carries private health insurance, which is supplemented by New Hampshire Medicaid. Without this crucial supplement, his parents fear Lucas would need to be placed in a residential facility, likely located out-of-state, which would rip the family apart, causing immeasurable harm to Lucas’ wellbeing. Many families would face similarly unthinkable outcomes if stripped of their coverage.

H.R. 1, the budget reconciliation bill passed by Congress and signed into law by the president on July 4, will cut $1 trillion from Medicaid programs over the next decade. Any cuts to Medicaid will be devastating to children’s health nationwide. These programs cover half of all children (approximately 37 million) in the country. It’s hard to imagine that our nation will be taking such a significant step backwards 60 years after such monumental legislation. 

In New Hampshire, some 90,000 children covered by Medicaid (known as AmericareHealth Caritas, NH Healthy Families, and WellSense) stand to be affected. At Dartmouth Health Children’s, like all children’s hospitals, more than a third of our patients are covered by the program. If those Medicaid reimbursement dollars, which already do not cover the actual costs of healthcare services we provide to patients, are in any way reduced, it could imperil the future of our children’s hospital, gutting children’s healthcare in our region.

The state may not have a choice. As it is, the federal government covers only a portion of Medicaid reimbursements, with the state responsible for the balance. The new law reduces the amount of federal matching dollars that will come to New Hampshire, leaving the state to cover the rest. Gov. Kelly Ayotte and the legislature already struggled to pass a balanced budget for this two-year cycle, and every added dollar for Medicaid leaves fewer for other important priorities like education, public safety, and infrastructure.

Proponents argue that the federal cuts to Medicaid spare children. Yet onerous administrative and work requirements will decrease the number of New Hampshire adults covered by an estimated 19,000, undoing the benefits of Medicaid expansion under the Affordable Care Act. We know that people and families who are uninsured delay medical care, only for their conditions to worsen to the point where they are forced to seek emergency care, which ultimately costs far more. Those higher costs are absorbed by healthcare systems like Dartmouth Health and are ultimately passed along as higher prices and health insurance premiums for all.

But the delicate balance of healthcare funding, at both freestanding children’s hospitals and those that are part of health systems, such as Dartmouth Health Children’s, is fragile at best. Across Dartmouth Health, it costs an estimated $300 million to care for all New Hampshire Medicaid beneficiaries, children and adult, yet we currently receive only $100 million in Medicaid reimbursements for that care. At some point, we cannot continue to subsidize such losses, and since we care for children regardless of their family’s ability to pay, we would be faced with considering closing entire programs and services. Once services are discontinued, they are not likely to be restored.

Every day, we care for families like Lucas’, facing some of the hardest moments of their lives. They come to our children’s hospital – the only one in the state of New Hampshire – because their child is acutely sick, seriously injured or in need of specialized care. Dartmouth Health Children’s is a critical safety net that hopefully you and your loved ones will never need, but if you do, you will thank your lucky stars that the region’s top specialists are here to apply their expertise to save your child’s – or grandchild’s – life.

It will be two years before the most draconian cuts to Medicaid take effect. That gives all of us time to advocate to our state and federal governments to come up with something even better for Lucas and all children, like they did 60 years ago today. 

Keith J. Loud, MD, MSc, is Dartmouth Health's Children’s physician-in-chief and chair of pediatrics at Geisel School of Medicine at Dartmouth College. He lives in Norwich, VT.